Sociocultural and patient-health care professional related factors influencing self-management of multiethnic patients with multimorbidities: A thematic synthesis

Self-management is critical for the general well-being and disease management of individuals with multimorbidities. A better understanding of sociocultural and patient-professional level factors affecting self-management can be valuable for designing individual and community-based strategies to promote optimal self-management. The purpose of this review was to explore sociocultural and patient-health care professional related factors affecting self-management among patients with multimorbidities. A metasynthesis was conducted. Literature was searched in PubMed, CINAHL, Scopus, Web of Science, and OVID databases. In total, 21 qualitative studies published from January 2010-March 2023 were critically appraised and reviewed. Thematic synthesis was used for analysis and eight descriptive and three analytical themes were generated. The analytical themes illustrated that personal and structural vulnerabilities, social and family struggles, and fragmented interpersonal relationships with health care professionals affect health care access, navigation, and self-management of individuals with multimorbidities. Engagement in self-management for individuals with multiple chronic conditions is hampered by under-resourced community and health care environments, structural vulnerabilities, familial and interpersonal conflicts, and disjointed relationships. There is a dire need to ensure optimal community resources to support individuals to address and navigate complexities associated with accessing care and effectively managing their illnesses.

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Multimorbidity, defined as two or more chronic conditions, is an emerging issue for individuals and health care systems globally. 13] Self-management in chronic illnesses refers to "the intrinsically controlled ability of an active, responsible, informed and autonomous individual to live with the medical, role and emotional consequences of his chronic condition(s) in partnership with his social network and the healthcare provider." 4, 10 Self-management is critical for individuals with multimorbidities.These individuals need to frequently visit general health settings and specialized care units to screen for complications, assess ongoing and emerging needs, and seek guidance on their self-management plans.[4][5] However, the ability of these individuals to seek health care guidance and engage in optimal selfmanagement is affected by personal, interpersonal, sociocultural, and health system-related factors.3 Reviews synthesized outlined experiences of individuals with multimorbidities, nature of self-management, priorities of self-management, and individuals' experiences with health care processes.Two reviews 3,6 highlighted some personal, interpersonal, and system-level issues encountered by these patients when striving for self-management.However, there is a gap in knowledge about critical sociocultural and patient-health care professional related factors affecting self-management of patients with multimorbidities.Gaining this understanding is essential to tackle contextual social and cultural factors impacting self-management and develop strategies to assist these individuals in performing optimal self-management.

Purpose
The purpose of this review is to explore sociocultural (e.g., ethnicity, gender, cultural orientation) and patient-health care professional related factors (e.g., interpersonal relationship and communication) affecting self-management among individuals with multimorbidities.

Burden of Multimorbidity
The increasing incidence of multimorbidity leads to a global burden. 7An estimated relevance of multimorbidity in high and middle-income countries, based on a review of 76 studies, is 33.1% with a pooled prevalence of 37.9% in high-income countries and 29.7% in low and middleincome countries. 8Recently, Abebe et al. 9 noted an increased prevalence of multimorbidity in low and middle-income ranging from 3.2% to 90.5%.0] Ofori-Asenso et al. 10 estimated an overall prevalence of 66.1% in older adults.They also noted that, when a definition of three or more chronic conditions was used, 56.5% of individuals were considered to have multimorbidity.The increased prevalence of multimorbidity is associated with worst health outcomes, increased use of health care resources, and reduced functional and system capacity. 11

Importance of Self-Management in Multimorbidity
Self-management can play an instrumental role in enhancing the physical and psychological well-being and functioning of individuals with multimorbidities, thereby reducing deteriorating health outcomes and improving functional and system-level capacity.Fortin et al. 12 and Contant et al. 13 demonstrated that a multifaceted self-management intervention (i.e., education about nutrition, lifestyle, motivation interviewing, and counseling) among individuals with multimorbidities improved their health-directed behaviors, emotional well-being, selfmonitoring, constructive attitudes, self-management skill and technique acquisition, and health services navigation.Dineen-Griffin 14 , after a systematic review of 58 studies, noted that selfmanagement has the potential to improve clinical outcomes, quality of life, self-efficacy, confidence, and disease control for individuals.The self-management interventions focused on providing knowledge about the chronic conditions, improving patient role in lifestyle changes, psychological coping, problem-solving and/or decision-making skills, medication adherence, developing self-management plans, and keeping self-monitoring logs.Of 58 studies, nine studies found a positive impact of self-management interventions on disease-specific outcomes, four studies noted improved self-efficacy, eight reported improved health-related quality of life, three studies demonstrated improved physical and social functioning, and 11 studies found a positive effect on psychological functioning.

Reviews of Literature on Self-Management and Multimorbidity and Gaps
Previous reviews focused on self-management in older people living with cancer and multimorbidities 15 , characteristics of self-management in individuals with multimorbidities 3 , priorities of individuals with multimorbidities 16 , lived experiences of multimorbidity and managing physical and mental health issues 17 , and experiences with multimorbidities and the health care processes. 6Two of these reviews outlined some personal, interpersonal, and health care system-related issues affecting the self-management of individuals with multimorbidities.
For example, van der Aa et al. 6 discussed that these individuals fail to receive holistic care due to the issues surrounding communication and relationship with health care professionals, lack of advocacy, health care access, and resources (interpersonal and system-level issues).Gobeil-Lavoie et al. 3 elaborated that individuals with multimorbidities focus on managing one condition at a time and do not receive adequate information from health care professionals on disease management (interpersonal issues).This, in turn, affects their emotional and physical health and makes them susceptible to complications.Self-management can have many physical, psychological, and disease-related outcomes in patients with multimorbidities. 14While existing reviews offer some insights about factors affecting the self-management of individuals with multimorbidities, no reviews have synthesized the sociocultural and patient-health care professional related factors affecting the self-management of multiple chronic conditions.

Methods
p. 1358 We followed the PRISMA guidelines for reporting the metasynthesis. 21(Supplementary File)

Literature Search
An exhaustive literature search 19 was performed in five databases to identify studies published from January 2010 until March 2023.The literature search was limited to these years to capture more contemporary literature on the topic.The databases included: Cumulative Index to Nursing and Allied Health Literature (CINAHL) (n =335), PubMed (n=580), Scopus (n =501), Web of Science (n=207), and Ovid (Medline) (n=403) using the indexed terms, keywords, subject headings, and MESH terms.These search terms and MESH headings were first identified from PubMed and compared with the search terms from other databases to choose the most pertinent terms and subject headings.The terms included: "sociological factors,", "sociocultural determinants", "patient perspectives", "patient experiences", "multimorbidity*", "comorbidity", "multiple chronic conditions", "health care access", "health care services", "health care accessibility", "self-management*", "self-care", "qualitative", "lived experiences", "perspectives", and "professional-patient relations*".Additionally, terms and keywords related to qualitative research methodologies such as "phenomenology", "narratives", "case study", "grounded theory", "exploratory qualitative", and "descriptive qualitative" were also used.The tiab-terms and truncation strategies were combined with names of qualitative study designs and Boolean variables "OR" and "AND" for advanced search.Search strategy for PubMed is presented in Supplementary File 1.

Inclusion and Exclusion Criteria
The inclusion criteria were: a) empirical research published from January 2010 to March 2023 in the English language in peer-reviewed journals, b) original qualitative studies including case studies, narratives, phenomenology, grounded theory, ethnography, descriptive qualitative, exploratory qualitative, and interpretive descriptive designs, c) qualitative studies including individuals with at least two or more chronic conditions as the target population and sample, d) studies that explored the lived experiences of self-management or self-care, and e) studies about individuals experiences and perspectives about social and cultural factors affecting their selfmanagement.The exclusion criteria included: a) qualitative, quantitative, and mixed methods studies focused on socio-cultural determinants and factors and their influence on health care access for patients with chronic diseases, but without multimorbidities, b) quantitative and mixed methods studies about sociocultural determinants affecting self-management in individuals with one or more chronic conditions, and c) literature reviews, discussion papers, dissertations, commentaries, editorials, and opinion pieces about the very topic.

Search Outcomes
In total, 2032 articles were identified from all the databases.After manually removing duplicates (n=971), 1061 articles were screened by reading the abstracts and titles.Two independent reviewers (AY & SS) screened the titles and abstracts.Of these articles, only 31 articles were relevant for full-text screening.These records were sought for retrieval, and all of these records were successfully retrieved.These 31 articles were subjected to full screening, but only 21 met the inclusion and exclusion criteria.The detailed search outcomes are presented in the PRISMA diagram (Figure 1).

Data Extraction
Data were extracted using the summary tables in Excel.The tables included information about authors, country, purpose, study design, setting, sample characteristics, sampling technique, method of data collection, methods of data analysis, significant findings, and strengths and limitations. 22This extraction was performed independently by two authors (AY & SS).The extracted results were compared, discrepancies were resolved, and tables were revised after consensus among all authors (AY, SS, AD, EM, CITG).

Critical Appraisal
The VAKS (Danish acronym for appraisal of qualitative studies) tool was used to critically appraise the articles. 23This tool includes 30 items for critical appraisal of qualitative research.
The items cover general requirements (6 items), credibility (7 items), transferability (5 items), dependability (6 items), and confirmability (6 items) of qualitative studies.The authors who extracted the data also performed the critical appraisal and scored each item on a four-point Likert scale from totally disagree=1 to totally agree=4.The total score for each criterion was calculated by adding the points for each criterion and dividing the number by the number of criteria.The cut-off values were strong>15, moderate =10 to 15, and weak<10. 23We performed this appraisal to evaluate the quality of the literature.However, we did not exclude any studies based on the quality scores.The studies were rated as strong, moderate, and weak.The weaklyrated studies were not excluded to prevent the risk of losing crucial contextual information. 19wever, during synthesis, the findings from strongly and moderately rated studies were given more weightage by sharing their findings and direct quotes under the developed themes.The findings from weakly rated studies were used to support the synthesized themes.

Data Synthesis
Thematic synthesis was used for data synthesis. 24It includes coding, developing descriptive themes, and generating analytical themes.At the coding step, two reviewers (AY & SS) independently reviewed the study findings, themes, sub-themes, categories, meanings units, participants' quotes, and the discussion section of the articles.Relevant phrases, words, findings, and quotes were coded using free line-by-line coding incorporating in vivo and open techniques.
The similar codes were combined into descriptive themes based on their relations and underlying and apparent meanings and organized into hierarchical structures.It was ensured that descriptive themes were kept close to the original codes and findings. 24The descriptive themes were evaluated by understanding the overall narrative of the studies and generating interpretations at an abstract level.The descriptive themes with similar and connected interpretations were synthesized into analytical themes (i.e., abstract themes generated after collating the descriptive themes and going beyond their apparent meanings).After the generation of analytical themes, the reviewers (AY & SS) conducted meetings to combine and finalize the themes.The remaining three reviewers (AD, EM, & CITG) reviewed the finalized themes and offered comments and suggestions for further improvement.During this synthesis process, reflective journals were maintained to write down interpretative notes and critical considerations for generating appropriate descriptions of findings.Reflective writing also enabled noting down pre-conceived biases and views about the topic and acknowledging how these assumptions may have influenced interpretations.

Findings Literature Overview and Quality Rating
Of 21 studies, most of the studies originated from the USA (n=5) and Australia (n=4), Canada (n=3), UK (n=3), and New Zealand (n=2), followed by one each in South Africa, Ghana, the Netherlands, and Denmark.The commonly used research designs were descriptive qualitative approach (n = 12) and phenomenology (n=6) while others used ethnography, case study, and secondary qualitative analysis.The sample size ranged from 11 to 85 participants with at least two multiple chronic conditions.The most common sampling techniques were purposive and convenience.The methods of data collection included in-depth and semi-structured interviews, document analysis, ethnographic observations, field observations, and focus groups.A wide range of data analysis methods were used, such as thematic analysis, conventional content analysis, Colaizzi's phenomenological method, and framework-based analysis (Table 1).Most studies were rated as high (n = 8) and moderate (n = 6) in quality.Four studies were rated weak in quality.The moderately and strongly rated studies had the following strengths: diverse and adequate samples, rigorous data analysis, detailed and rich description of methods and findings, triangulation, reflexivity, and data saturation (Table 1).

Demographics
Based on the demographic data presented in all of the studies, it was identified altogether 252 men, 283 women, and one trans individual with an average of 4.5 multiple chronic diseases were interviewed.All of the individuals were above 30 years of age.Of these individuals, 219 were non-Caucasian (e.g., Asian, South Asian, African American, Latino, Hispanic), 208 were Caucasian, and 108 were Aboriginal.A large percentage (69%) of individuals belonged to the low and middle-income group, were retried, unemployed, or on a disability pension.The common chronic diseases included hypertension, diabetes, hyperlipidemia, arthritis, cancer, coronary artery disease, chronic obstructive pulmonary disease, mental health problems, depression, generalized anxiety, arthritis, psoriasis, obesity, gastrointestinal problems, substance abuse disorder, and psoriasis.

Thematic Synthesis
Eight descriptive themes and three analytical themes were developed from all studies  . The temes are discussed and the detailed thematic synthesis is illustrated in Table 1.

Access to Care and Navigation of Health Care Delivery Systems
This analytical theme comprised three descriptive themes: living circumstances and vulnerabilities, scarce health resources, and intrusive health care delivery system.Individuals with multimorbidities in self-management were constrained by personal and structural vulnerabilities that varied across different contexts and life circumstances.Limited health care facilities and personal and community resources impacted their access to distant health care services.If they could access the services, they would experience challenges navigating the arduous health care system.This theme was more apparent in the narratives of individuals with diabetes, hypertension, respiratory problems, substance abuse, and mental health problems.
Many individuals described that initially, they had the finances to manage their health care problems.However, as their health care conditions deteriorated and needed more self-care, they ran out of funds.They had to pay out of pocket for basic medical needs such as medications and equipment for self-care.Lo et al. 30 reported that individuals felt stressed because they had to travel a long distance to seek health services, payout of pocket for essential services, and incidental costs such as car parking.Limited finances made it difficult for them to make a difficult choice of staying home and avoiding seeking care.
Such living circumstances prevented them from seeking care and engaging in selfmanagement and affected their emotional health, leading to stress, confusion, uncertainties, and fears.Sav et al. 35 noted that medicinal and consultation costs instigated the financial burden.The individuals felt worried and concerned if they could manage their multiple health issues.
Analysis of individuals' experiences in the reviewed studies indicated that Self-management was for the privileged, and individuals with structural, personal, and social vulnerabilities struggled to care for themselves while also striving to meet the needs of their families."The money is not enough.I can't even afford my rent and diabetes foods.I also need to buy foods and medication for my wife.I only try to buy whatever I can, but I never get to achieve what the doctor recommends [. ..].Although I adhere to my medications, I do not see much changes.p. 379 Scarce Health Care Resources Individuals described a lack of health care resources and services which made self-management a complex and tiresome process.The health care centers, and specialized care services were at a distance from individuals' homes and most of them did not have transportation.In the communities, there was a shortage of medical supplies. 25, 27-28, 30, 32, 34, 36The individuals did not have health care insurance to meet the expenses of medical and specialized care.Those who had insurance received reductions and cutbacks because of their multiple complex health care needs and they expressed that their insurance was not sustainable.Ho et al. 32 noted that some individuals received home care services and covered the expenses through private insurance.
However, financial challenges and disease burden resulted in cutbacks in the hours and visits received from formal caregivers.
Lack of health care resources in the communities and the inability to travel to distant hospitals prompted many individuals to put greater emphasis on home remedies and herbal medicine to manage their health issues. 26,34 he use of herbal and traditional medicine was also prompted by social and cultural beliefs, lack of medical centers, and peer pressure.Given the shortage of medical facilities, many traditional healers often encouraged individuals to give up their prescribed medicines.Morgan et al. 37 described that women with HIV and multimorbidities bought herbal medicines from local vendors and churches.
Many individuals did not have family doctors so it was almost impossible for them to seek medical advice and consultation when needed. 32The lack of facilities and health centers in the communities aggravated their conditions, further adding to the issues of seeking medical support.
These individuals had to travel to far-off places to talk to specialists.Signal et al. 38 discussed that many individuals had to see professionals in primary care because they no longer had a family doctor.Individuals with diverse ethnic backgrounds noted that when they can access health care services, they cannot explain their issues because of the lack of interpreters in health care centers. 30They get cut back.Like with the PSW, I was given 3 times a week and then when they start getting towards the end of the budget, the money's running down, then you get cut back.
p. 1314 Intrusive Health Care Delivery System Individuals discussed that the health care system is challenging to navigate because the bureaucracy gets in their face when they try to seek care and support.They explained the difficulties in scheduling their appointments, switching health care professionals, and providing the paperwork for seeking health care services. 29-30, 32, 34, 36-39They noted a lack of coordination among health care professionals resulting in costing them their appointments and consultations.30, 35, 38, 40, 41, 42 Individuals living in poor housing and unstable shelters experienced struggles to seek medical attention when needed.They experienced logistic struggles in making, attending, and changing their appointments. 32,35,42 Ividuals noted bureaucracies that affected their ability to seek health care services.Some individuals did not have the paperwork, or the documents needed to avail themselves of the services.][30][31][32] Villena and Chelsa 42 noted that navigating institutional bureaucracies within the Medicaid system was a consistent struggle.This struggle was worsened if they also lived in unkempt and dangerous housing accommodations.Such health system issues combined with social vulnerabilities affected individuals' trust in the health system and its efficiency to address their multiple needs. 27,32,39 " State said I'm not eligible for Medicaid.But we have a diagnosis of diabetes, emphysema, and now, cancer.Why?Because I worked?I gave up my job, and I still didn't get the Medicaid.I had no medical insurance.I had to fight them.I went to Legal Aid.The State said I defrauded them because I worked.I finally got my Medicaid in July.I got the energy and got up and fought the system and their red tape because I needed to.I needed the Medicaid, or what was I gonna do?Just die?p. 82 Analytical Theme Two: Social and Family Struggles limit Health Care Access and at Home

Self-Care
Individuals expressed that some covert sociocultural issues about social hierarchies and family systems impact their ability to access health care services and perform self-care at home.Individuals with different ethnicities were often denied essential health care services because of bureaucratic issues.While women had to depend on their families to access health care and financial expenses for self-care.These two struggles were widespread for individuals in low and middle-income countries and those with different ethnic backgrounds.This theme was more apparent in the narratives of individuals with diabetes, hypertension, coronary artery disease, AIDS, chronic obstructive pulmonary disease, and mental health problems.

Intercultural Issues
Two intercultural struggles were ethnic and gender differences.Individuals from diverse ethnic backgrounds experienced more challenges to access healthcare services than native residents.
The bureaucratic health care system greatly influenced this intercultural issue because those with different ethnic backgrounds had to provide more paperwork to prove that they qualified for health care services.Bosire et al. 26 shared an account of a woman who did not speak and understand English and required her sister's help during the clinical appointments.Her mother was Lesotho and her father was a South African.They passed away because of HIV.She and her siblings were denied the right to be a South African citizen.Therefore, she did not have any proof making her eligible to access primary care services offered by the government.Lo et al. 30 discussed that some patients expressed that being a non-English speaker with different ethnicity and culture characterized by apathy negatively influenced self-management and dietary restrictions.Pertaining to gender discrimination and self-management, only one study noted that 37 women face more issues in accessing care and engaging in self-care because they were dependent on their families and community to offset the financial burden of chronic disease management and treatment.
"As for that one my child, eating is even difficult for us.…The time that I am supposed to eat, I don't get food to eat … It is only the boys who support me a little.It is almost one year since I got paralysed and none of them have called on phone to find out how I am doing.If I don't call them, then I would not hear from them.p.11

Intrapersonal Familial Struggles
The intrapersonal familial struggle was conceptualized as individuals' tensions within their families and, or with family members, affecting their self-management.2] Many of these individuals had to rely on their families for financial, physical, and emotional support.] Some individuals considered their family as the source of stress which prevented them from fully engaging in self-management of their multiple health care issues. 28, 37, 40,Individuals also noted that focusing on self-care sometimes led to feelings of guilt for not caring for their families. 29,40 y often had to make a deliberate choice of competing family priorities 28 and sacrifice their own needs for their family members which created intrapersonal tensions. 29I mean a lot of that has been completely on my wife as far as paying the house note and most of the bills through a lot of this, and that's caused tension, of course… We have been on this kind of rocky road."29, p. 44 Analytical Theme Three: Fragmented Interpersonal Relationship Reduces self-

Management Preparedness and Ability
This analytical theme captured the patient-care professional relationship and how it affected the self-management ability of individuals with multiple chronic conditions.It entails three descriptive themes illustrating epistemic battles among patients and health care professionals, their relational conflicts, and the quality of health education provided by health care professionals.The interaction between providers and patients was fragmented and negatively influenced individuals' self-management ability and preparedness.The individuals had to mainly rely on themselves to perform adequate self-care.This theme was more apparent in the narratives of individuals with diabetes, coronary artery disease, chronic obstructive pulmonary disease, respiratory problems, psoriasis, and menta health problems.

Epistemic Battles
Many individuals had health care problems (e.g., AIDS) which are often stigmatized among the general public and communities.][39] The individuals noted that they felt voiceless in front of health care professionals because their concerns and complaints were not listened to attentively. 34,29,37,42 Of the health care professionals asked the patients not to schedule any appointments unless necessary without considering the needs and viewpoints of the patients. 41,43 ] Generally, the individuals struggled to explain their perspectives to their health care professionals. 42ou can phone in and the doctor will talk to you or you can phone a nurse and they will talk to you.'Please don't make an appointment unless it is absolutely necessary.'Well, what do you know is absolutely necessary?p. 62

Relational Conflicts
Individuals discussed that while navigating the complex health care services and managing their chronic issues, they had many conflicts with health care professionals. 29,30,36,42 Th conflicts were varied in nature.0][31][32] Many individuals noted that the source of the conflicts was often non-caring attitudes, lack of attention from health care professionals, and bureaucracies surrounding health care access and services. 26,29,30,41 Reational conflicts shattered patients' trust in health care professionals, thereby affecting individuals' ability and preparedness to perform self-management. 27,29,42 Te lack of trust in health care professionals also stemmed from past negative experiences in health care. 27 few days after my appointment, I noticed that my sugars were high in the morning when they shouldn't have been.So then that's when I realized, oh, this is N, and not 70/30.I called and left a message on the doctor's voice mail.She was on vacation, but I knew that she would pick it up Monday.And she called on Monday and said, "Oh, yes, I did give you the wrong insulin."p. 80

Substandard Health Education
Individuals raised concerns about substandard health education from the health care professionals.Many individuals noted that the health care professionals completely ignored educating them about their disease, treatment, and care modalities. 30, 33-35, 42, 41, 44,45However, others noted that the education was delivered with jargon-loaded language without considering the education level and needs of the patients. 30,33 [44] Concerns were raised that health professionals were time-poor and did not take the initiative to offer any health education or explanations unless asked by the patients. 30,34,43 I health education was offered, individuals noted a lack of follow-up from health care professionals. 38,40,41 Givn the lack of quality health education, most patients relied on trial and error learning for self-education and explored their resources to learn about disease management. 31and I ask the doctor, 'What's diabetes?' Sugar is high … even today I still puzzled because they are not explained properly how high … the sugar [is].p. 231

Discussion
This review aimed to synthesize literature about experiences and perspectives of individuals with multimorbidities to understand sociocultural and patient and health care professional level factors affecting their self-management ability.The principal findings of this review are that individuals with multimorbidities self-management are affected by personal and social vulnerabilities, familial struggles, and fragmented interpersonal relationships with health care professionals.Socio-cultural factors such as poverty, economic circumstances, living and housing conditions greatly affect their access to and usage of health care services to complement their own self-management efforts.If they are able to access health care services and resources, they struggle to navigate the arduous health care system and bureaucracies and experience epistemic struggles and conflicts with health care professionals.These findings are consistent with previous reviews 3,6 that identified that individuals with multimorbidities struggle to access health care and fail to receive holistic care for their health care issues.
The findings of this review bring into attention the importance of structural competency for health care professionals and the need to design better structural interventions in health care organizations.Structural competency enables in understanding the impact of socio-cultural and demographic determinants such as race, class, gender, and ethnicity on health care professionals' encounters in relation to the broader structural contexts in which their encounters take place. 46alth care professionals should be trained to become more culturally competent in order to address socio-cultural factors and foster the relationship among health care professionals and individuals with multimorbidities.Additionally, training should also include effective management of chronic disease management and care processes to better prepare individuals for self-management. 47alth care organizations should focus on developing and implementing more targeted interventions to provide effective care to individuals with multimorbidities by placing mechanisms to address the negative impact of sociocultural determinants.9] The utilization of such mechanisms is particularly important in low and middle-income countries which may have a public-funded health care system but no health insurance for meeting additional expenses.[50][51][52] Therefore, existing interventions implemented in diverse contexts could be contextualized using implementation science methods and tools to implement in new settings.One critical consideration for designing and contextualizing such integrated and comprehensive care programs is that these programs should be person-centered and tailored to the felt needs of individuals with multimorbidities. 50,52 erson-centered programs should include better assessment of patients' needs, therapeutic relationships among health care professionals and patients, and sustainable health education to foster self-management. 47,50

Limitations
Only English language studies were included which could have resulted in missing any additional studies on the very topic.While performing thematic synthesis subjective and value judgments were made for developing descriptive and analytical themes which may have influenced the validity of the review.Nevertheless, multiple reviews and independent assessments were taken to ensure that personal biases do not affect the interpretation of reviewed literature.Most of the reviewed studies originated from the USA, Canada, and Australia.
Therefore, the transferability of findings to other contexts may be limited.Further research is warranted in other areas of the world.

Conclusions
Self-management is instrumental for individuals with multimorbidities in managing their complex health care issues and unanticipated potential complications.However, engagement in self-management for these individuals is hampered by under-resourced community and health care environments, personal and structural vulnerabilities, familial and interpersonal conflicts, and disjointed and fragmented relationships with health care professionals.There is a dire need to ensure optimal community resources to support individuals to address and navigate complexities associated with accessing care and effectively managing their illnesses.The relationship between health care professionals and individuals with multimorbidities was found to be fragmented due to epistemic struggles and relational conflicts.Therefore, training for structural and cultural competence of health care professionals can be promising to better prepare them to address socio-cultural determinants and negative individual level factors affecting their abilities to provide effective and person-centered care.